RULES AND REGULATIONS FOR PROGRAM ADMINISTRATION OF HOSPICE PROGRAMS by mariolopez

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									                          RULES AND REGULATIONS
              FOR PROGRAM ADMINISTRATION OF HOSPICE PROGRAMS

CHAPTER 10

        Section 1.     Authority.      These rules are promulgated by the Department of Health
pursuant to W. S. §9-2-1204 et seq., and the Wyoming Administrative Procedure Act W. S. §16-3-101
et seq.

      Section 2.       Purpose.        These rules have been adopted for the day-to-day operation of
Hospice Programs.

       Section 3.     Severability. If any portion of these rules is found to be invalid or
unenforceable, the remainder shall continue in effect.

       Section 4.      Definitions.

         The following definitions shall apply in the interpretation and enforcement of these rules.
         Where the context in which words are used in these rules indicates that such is the intent, words
in the singular number shall include the plural and vice versa. Throughout these rules, gender pronouns
are used interchangeably. The drafters have attempted to utilize each gender pronoun in equal numbers,
in random distribution. Words in each gender shall include individuals of the other gender.

       For purpose of these rules the following shall apply:

       (a)    “Bereavement” means the period of time during which the hospice patient’s family
experiences and adjusts to the death of the hospice patient.

     (b)      “Bereavement Services” means those services available to the surviving family
members for a period of at least one year (1) after the death of the patient.

       (c)     “Chief Administrative Officer” means the Director, Department of Health, per W. S. §9-
2-101(e) or the designated Licensure representative.

       (d)      “Central Registry” means the registry operated by the Wyoming Department of Family
Services pursuant to W. S. §14-3-213, which indexes perpetrators of child abuse or neglect and abuse,
neglect, exploitation or abandonment of disabled adults. The registry information is available by calling
307-777-5894.

       (e)     “Complaint Investigations” means those investigations required to be performed by the
Long Term Care Ombudsman per W. S. §9-2-1301 through W. S. §9-2-1309 or by the State Survey
Agency as per the Agreement between the Secretary of the U.S. Department of Health and Human
Services and the State of Wyoming dated June 18, 1985.

        (f)      “Continuous Home Care” means those services provided when the patient is not in an
inpatient facility and receives hospice care consisting predominantly of nursing care on a continuous
basis in the patient’s residence. A minimum of eight (8) hours of care must be furnished on a particular
day.

        (g)    “Day Care Center” is an optional part of the hospice program, which provides health and
social services to a patient on a regularly scheduled basis. The day care center is governed by the
licensed hospice program.

       (h)      “Direct Care” means a hospice service delivered in a place other than the patient’s home,
such as a freestanding facility or a designated hospice unit within a nursing care facility or hospital.

       (i)     “Employees” means paid or volunteer members of the hospice team.

        (j)     “Family” means those individuals who are closely linked with the patient including, but
not limited to, the immediate family, the primary care giver, and individuals with significant personal
ties. The patient and family is considered the unit of care.

        (k)    ”Fidelity Bond” means a contract of fidelity insurance, in which there is an agreement to
insure another against loss arising from the want of honesty, integrity, or fidelity of an employee of the
hospice program.

        (l)     “Hospice” means a program for the terminally ill and their families given in a home or
health facility which provides medical, palliative, psychological, spiritual and supportive care and
treatment.

        (m)    “Hospice Patient” means a person diagnosed as terminally ill. This person, alone or in
conjunction with a family member or members, has voluntarily requested admission and been accepted
in the hospice program.

       (n)    “Hospice Volunteer” is a professional, paraprofessional, or lay person trained in
providing support, patient care, or companionship to the patient and family.

         (o)     “Inpatient Respite Care” means the care provided to a hospice patient in an approved
facility to allow for caregiver respite.

       (p)      “Interdisciplinary Team” means a group of individuals who collectively have expertise
in meeting the special needs of the hospice patient and his/her family. Appropriate staff/volunteers are
included as needed. Coordination and communication among team members is carried out on a regular
basis.

       (q)     “Licensing Division” means the Department of Health, Office of Health Quality.

        (r)    “Licensed Health Care Professional” means a physician, registered nurse, psychologist,
or social worker who has a current State of Wyoming license to practice his/her profession.

       (s)    “LSC” means NFPA 101 Life Safety Code cited in the Department of Health, Chapter III
Construction Rules for Health Facilities.
        (t)     “Medical Director” means an individual who is a doctor of medicine or osteopath,
licensed by the State of Wyoming, and who is designated by the hospice as having overall responsibility
for the medical component of the hospice program.

       (u)     “NFPA” means the National Fire Protection Association.

       (v)     “Nursing Services” means those services provided by or under the direction of a
Registered Nurse based on a plan of care developed by the interdisciplinary team. These services may
be provided by Licensed Registered Nurses, Licensed Practical Nurses, or Certified Nursing Assistants/
Home Health Aides as appropriate.

       (w)     “Palliative Care” means comfort care rather than curative care with an emphasis on pain
and symptom control so a person can live the last days of life with dignity and comfort at home or in a
home-like setting. Palliative care:

               (i)     affirms life and dying as a normal process;

               (ii)    neither hastens nor postpones death;

               (iii)  provides relief from pain and other
distressing symptoms;

                (iv)    integrates the psychological and spiritual
aspects of patient care; and

               (v)   offers a support system to help the family cope during the patient’s illness and in
their own bereavement.

      (x)     “Program Administration” means the rules and regulations promulgated by the
Department of Health and developed by the program division for the day-to-day operation of the
Hospice Program per W. S. §9-2-1208.

       (y)     “Program Division” means the Department of Health, Division on Aging.

                     (aa) “Psychosocial Counselor” means an individual who possesses a
baccalaureate degree in social work, psychology, counseling, or the documented equivalent in a
combination of education, training, and experience.

                       (bb) “Psychosocial Services” means those counseling and casework services
which address the social, economic, psychological, and emotional needs of patients and families.
Psychosocial services include, but are not limited to, psychosocial assessment of the patient and family,
counseling to assist with the stress of terminal illness, assistance in planning for care and coordination
of community resources.

                       (cc) “Routine Home Care” occurs when a hospice patient is in his/her
residence and is not receiving continuous care.
                       (dd) “Short Term Inpatient Care” means those services that a hospice patient
receives in an inpatient facility for pain control or other acute symptom management which cannot be
managed in other settings, or for caregiver respite.

                         (ee) “Spiritual Services” means those services that help patients and/or
caregivers to integrate the dying experience into his/her life; to find meaning and purpose in what
remains of life, and to further his/her appreciation of spiritual values that give support and hope in coping
with the changes that are taking place.

                        (ff)   “State Survey Agency” means the Department of Health, Office of
Health Quality which has the primary responsibility to determine whether health care providers/
suppliers do or do not meet federal certification standards to participate in the Medicare and/or Medicaid
programs as per the Agreement between the Secretary of the U.S. Department of Health and Human
Services and the State of Wyoming dated June 18, 1985.

                        (gg)    “Survey” means an on-site evaluation conducted by the Survey Division
or its designated representative to determine compliance with State of Wyoming Rules and Regulations
for the Hospice Program.

                        (hh)     “Survey Division” means the Department of Health, Office of Health
Quality.

                     (ii)    “Volunteer Services” means those services provided by trained hospice
volunteers who have agreed to provide service under the direction of a hospice program.

                              (i)     Hospice volunteers may be used to provide support, patient care,
and companionship to the patient and his or her family during the remaining days of the patient’s life and
to the surviving family following the patient’s death.

                                  (ii)    Volunteers may also provide supportive services to the hospice
staff in areas such as, but not limited to, assisting in the office, public relations, and other various hospice
activities.

        Section 5. Organization and Management.

        (a)    Governing Body. The hospice program shall have a governing body which has the legal
authority and responsibility to operate the hospice program. The governing body shall:

                 (i)    Obtain a fidelity bond for patient protection due to dishonesty, integrity, or
fidelity on behalf of an employee. The bond shall consist of no less than $2500 and shall be augmented
in relation to the number of employees.

                  (ii)     Provide verification of a central registry check on all employees hired at the time
of or after the filing of these rules. The individual agencies or corporations are responsibe for obtaining
central registry verifications. Central Registry information can be obtained by contacting the
Department of Family Services at 307-777-5894 (this number may be subject to change).
               (iii)   Adopt, revise, and approve personnel policies, including:

                       (A)     Frequency of evaluations; and

                       (B)     Insuring confidentiality of central registry information checks.

                (iv)    Prepare an organizational chart that reflects the administrative control and lines
of authority for the delegation of responsibility from management down to the patient level.

               (v)     Ensure that all services provided are consistent with accepted standards of
practice.

               (vi)    Ensure adequate staffing to provide quality hospice care.

              (vii) Develop and implement policies and procedures for services offered, which shall
be reviewed annually by the governing body, or appropriate administrative representative.

             viii) Develop an effective, ongoing, agency-wide written quality improvement
program which ensures and evaluates quality of care to all patients in accordance with W. S. §35-2-910.

                       (ix)    Grievance Procedure.

                             (A)    The written grievance procedure shall establish a system of
reviewing complaints and allegations of patients’ rights violations to include, but not be limited to:

                                       (I)     Patient method to voice grievance;

                                       (II)    The Hospice Program’s written response to patient
grievances;

                                        (III) List of agencies, with addresses and telephone numbers
for patients to contact if grievances are not addressed satisfactorily; and

                                     (IV) Written reports on all grievances and resolutions shall be
provided to the Licensing Division, within ten (10) days after the grievance is filed.

                       (x)     Complaint Investigations.

                         (A)           Patient’s complaints and problems shall be referred in writing to
the Long Term Care Ombudsman.

                              (B)     The office of the Ombudsman shall complete all complaint
investigations within an appropriate time frame depending upon the nature of the allegations.

                               (C)     Written reports of an investigation and the status of resolutions
completed by the Hospice shall be provided by the Long Term Care Ombudsman to the Licensing
Division within thirty (30) days after the completion of an investigation.
                             Exception: Those complaints or problems reported directly to the State
Survey Agency or referred by the Long Term Care Ombudsman to the State Survey Agency shall be
investigated by the State Survey Agency as per the Agreement between the Secretary of the U.S.
Department of Health and Human Services and the State of Wyoming dated June 18, 1985.

                       (xi)     Personnel Records.

                              (A)    There shall be one (1) person designated responsible for
maintaining confidentiality of personnel records.

                       (xii)    Employee Health. The hospice program shall at least:

                             (A)      Develop policies and procedures for employee health including a
policy listing communicable diseases that put the patient population at risk, W. S. §35-4-107 through W.
S. §35-4-109 and;

                                (B)     Document that the employee is free of communicable diseases
that could be a risk to the client population.

                       (xiii)   Advanced Directives.

                             (A)     The hospice program shall adopt policies which assure that
information on advanced directives is provided to all patients. If the patient’s advanced directives are
known, they shall be followed by the hospice program.

                       (xiv)    Notification.

                          (A)    Prior to admission, all perspective patients shall be notified if the
hospice program is NOT Medicare/Medicaid certified.

                               (B)      Each hospice program will notify its prospective patients, or the
responsible party, of the services it provides and the charges for those services.

                                (C) The responsible party shall be notified of the service charges and any
change.

        Section 6. Patients Rights and Responsibilities.

               (a)     Each hospice patient/family shall receive a copy of the Hospice patients bill of
rights and responsibilities.

              (b)      The hospice program shall keep written documentation that each patient has
received a copy of the patient rights and responsibilities.

                (c)    By written declaration the hospice shall affirm the following patient rights and
responsibilities:
                       (i)    The right to be informed of the hospice concept, admission criteria,
services to be provided, options available, and any charges which may be incurred;

                       (ii)    The right to participate in developing the individual’s plan of care;

                       (iii)   The right to expect that all records will be confidential;

                       (iv)    The right to refuse service or withdraw from the program at any time;

                       (v)    The responsibility to provide accurate information which may be useful
to the Hospice in delivering appropriate care;

                       (vi)    The right to express a grievance without fear of reprisal; and

                       (vii)   The right to be free of any verbal or physical abuse of any kind.

               (d)      Hospice responsibilities shall include, but not limited to:

                       (i)     Provide quality care to patients regardless of race, religion, sex, age, and/
or physical or mental disabilities;

                       (ii)    Train all staff and volunteers adequately for the level of services they
provide;

                       (iii)   Provide care which is:

                               (A)     Ethical;

                               (B)     In the best interest of the patient;

                               (C)     Respectful to the patient/family life values, religious preference,
dignity, individuality; and

                               (D)     Privacy in treatment and personal needs.

                       (iv) Provide special attention to the patient’s right to privacy, choice, and dignity
including infants, small children and adolescents.

       Section 7. Admission Criteria.

       (a)      Admission criteria shall be clearly defined in the hospice program policies.

       (b)      Decisions regarding admission shall follow the established criteria of the program.
        Section 8. Hospice Day Care Services.

       (a)      The Hospice Day Care Center shall be staffed with qualified personnel, which may
include:

                           (i)     a registered nurse;

                           (ii)    licensed practical nurse; and

                           (iii)   certified nurse aide, in numbers sufficient to provide appropriate
services.

        (b)     The services shall include, but not be limited to:

                           (i)     emergency services;

                           (ii)    assistance in the development of self-care capabilities;

                           (iii)   personal hygiene;

                           (iv)    social support services; and

                           (v)     provision of nourishments appropriate to the hours in which the patient is
receiving service.

        (c)     Hospice Day Care Centers shall meet the following standards:

                           (i)     Provide a clean environment, free of obstacles that could pose a hazard to
client health or safety;

                      (ii)  Provide easily accessible toilet facilities, hand-washing facilities and
paper-towel dispensers, and

                           (iii)   Be accessible to patients with supportive devices for ambulation and
wheelchairs.

       (d)    The Hospice Day Care Center shall have written policies and procedures relevant to its
operation. Such policies and procedures include, but are not necessarily limited to:

                    (i)            Admission criteria that qualify patients to be appropriately served in the
Hospice Day Care Center;

                           (ii)    Meals and nourishments, including special diets that will be provided;
and
                     (iii)   Hours and days of the week services will be available in Hospice Day
Care Center and days of the week services will be available.

       (e)   The patient or responsible party and the hospice day care center shall have a written,
signed agreement outlining the respective rules and responsibilities.

       Section 9. Staff Inservice Training.

       (a)     The hospice program shall provide an initial training and orientation program as well as
continuing in-service education programs. The programs offered shall be appropriate to the services
provided by the Hospice.

       Section 10. Fire Safety and Emergency Procedures.

       (a)     Fire Safety.

               (i)     Hospice shall meet the Life Safety Code provisions.

       (b)     Emergency Procedures.

               (i)     Disaster and Emergency Preparedness.

                      (A)    The Hospice shall have detailed written plans and procedures to meet all
potential emergencies and disasters, such as fire and severe weather.

                      (B)     The Hospice shall train all employees in emergency procedures when
they begin work. Hospice shall review the procedures with existing staff at least once in each twelve (12)
month period.

                       (C)      Emergency numbers shall be located near the telephone in large print.

       Section 11. Licensing.

      (a)     Shall be in accordance with the current Licensure Rules and Regulations for Hospice
Programs as promulgated by the Department of Health.

       (b)     Copies of the licensure rules can be obtained from the Licensing Division.

       Office of Health Quality
       2020 Carey Avenue, 8th Floor
       Cheyenne, WY 82002
       Telephone (307) 777-7123

								
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